Pathways of Fluid Leakage in Age-Related Macular Degeneration

Capilliposide A relieved dry age-related macular degeneration through ROS/SIRT1/P53 signaling pathway

Age-related macular degeneration (AMD) is the main cause of vision impairment in the elderly, which still lacks efficient treatment. Capilliposide A (LC-A), a saponin-type anti-inflammation compound extracted from Lysimachia capillipes Hemsl, were used for investigating its anti-AMD effects. The cell viability of LC-A against ARPE-19 cell lines were detected by CCK8 assay. Flow cytometry assay was used for examining ROS accumulation and apoptosis. Dry AMD mice model was constructed by NaIO3 (i.v.). Then, the anti-AMD effects of LC-A were detected by optical coherence tomography (OCT) assay, electroretinogram (ERG) assay, H&E staining assay and immunofluorescence staining assay. Transcriptome analysis was used to screen the potential signaling pathway of LC-A treatment. Furthermore, Western Blot and immunofluorescence assay were used to verify the signaling pathway in vivo and in vitro. LC-A performed safety against ARPE-19 cell lines (under 25 μM). LC-A also showed significant inhibitory effects against apoptosis and ROS accumulation caused by NaIO3. Meanwhile, AMD mice model was significantly relieved by LC-A eye-drop treatment. Then, P53 signaling pathways influenced by LC-A was screened out by transcriptome. Results showed that LC-A could inhibit SIRT1/P53 protein expression levels verified by immunofluorescence and Western Blot. These results indicated that LC-A could inhibit apoptosis and ROS accumulation caused dry AMD through SIRT1/P53 signaling pathways, which showed clinical potential for treating senescence-related or SIRT1/P53 mediated AMD patients.

Real-World-Data of Treatment-Naïve and Previously Treated Patients Receiving Up to 3 Injections of Faricimab in Neovascular Age-Related Macular Degeneration

Purpose

To evaluate visual and anatomical outcome of consecutive patients who received intravitreal injections (IVI) of faricimab for the treatment of neovascular age-related macular degeneration (nAMD).

Patients and methods

A retrospective study of patients treated for nAMD with one to three IVIs of faricimab from October 2022 to January 2024. Demographic data, treatment history, best corrected visual acuity (BCVA), anatomic parameters, and adverse events (AEs) were collected.

Results

After one IVI of faricimab, previously treated (n=160) eyes with a mean of 33.51 IVIs and treatment-naïve (n=10) eyes showed a mean BCVA gain of +0.59±0.52 letters (p=0.364) and +5.00±6.50 letters (p=0.461), respectively, and a mean central subfield thickness (CST) reduction of -27.65±5.33 µm (p<0.001) and -94.10±39.74 μm (p=0.042), respectively. In treatment-refractory eyes after switching from aflibercept (n=108), mean BCVA increased by +0.42±0.66 (p=0.745) and the mean CST improved by -21.98±6.04 (p<0.001). After three IVIs of faricimab previously treated (n=106) and treatment-naïve (n=5) eyes showed a mean BCVA increase of +1.57±0.88 letters (p=0.051) versus +12.50±8.14 letters (p=0.185), and a mean CST reduction of -25.51±5.82 µm (p<0.001) versus -82.60±36.20 µm from baseline, respectively. In treatment-refractory eyes after switching from aflibercept (n=79), mean BCVA improved by +2.15±1.08 letters (p=0.029) and mean CST decreased by -27.46±7.04 µm (p<0.001). Mean pigment epithelial detachment (PED) was also significantly reduced even between the first and the third faricimab injection in previously treated eyes (p=0.03). The proportion of eyes with intraretinal fluid and subretinal fluid improved significantly in all eyes and treatment-refractory eyes after switching from aflibercept. Ocular AEs were reported in three out of 170 eyes, and one patient had two stroke events during faricimab therapy.

Conclusion

Three IVIs of faricimab have the potential to improve visual acuity and anatomical parameters even in treatment-refractory nAMD eyes with a mean dosing interval of more than 6 weeks.

Intravitreal Dexamethasone as a Rescue for Anti-Vascular Endothelial Growth Factor Therapy in Neovascular Age-Related Macular Degeneration with Persistent Disease Activity and High Treatment Demand

Purpose: To assess the impact of switching to, or adding, an intravitreal dexamethasone implant (Dex; Ozurdex®) in anti-vascular endothelial growth factor (VEGF) therapy on disease stability and treatment intervals in eyes with neovascular age-related macular degeneration (nAMD) and persistent disease activity and high treatment demand. Methods: This retrospective noncomparative multicenter longitudinal case series included pseudophakic eyes with nAMD and persistent retinal fluid despite regular anti-VEGF therapy (ranibizumab or aflibercept) that received at least 1 intravitreal Dex implant. Visual acuity, central retinal thickness (CRT), and intraocular pressure were recorded before, and after, the addition of Dex to anti-VEGF therapy. Results: Sixteen eyes of 16 patients met the inclusion criteria of persistent fluid despite anti-VEGF therapy, under treatment intervals of ≤7 weeks in 14 instances. Patients were 80.9 ± 7.4 years old and had received 25.5 ± 17.4 anti-VEGF injections before Dex over a period of 36.4 ± 21.9 months before switching. The treatment interval increased from 5.5 ± 3.2 weeks between the last anti-VEGF and first Dex injection to 11.7 ± 7.3 weeks thereafter (P = 0.022). CRT remained stable (385.3 ± 152.1, 383.9 ± 129.7, and 458.3 ± 155.2 μm before switching as well as 12 and 24 months after switching; P = 0.78 and P = 0.36, respectively). An insignificant mean short-term early increase in visual acuity was not sustained over time. Conclusions: The addition of Dex resulted in a relevant and sustained increase in treatment intervals, whereas CRT and visual acuity remained stable in these difficult-to-treat eyes. It may be discussed whether inflammation or other steroid-responsive factors play a significant role in cases of nAMD with nonsatisfactory responses to anti-VEGF.

CHARACTERISTICS PREDICTIVE OF FELLOW-EYE GEOGRAPHIC ATROPHY WITHOUT NEOVASCULARIZATION IN UNILATERAL TYPE 3 MACULAR NEOVASCULARIZATION

PURPOSE

To evaluate the predictive characteristics of fellow-eye geographic atrophy (GA) without neovascularization in patients with unilateral Type 3 macular neovascularization.

METHODS

This retrospective study included 84 patients who were diagnosed with unilateral Type 3 macular neovascularization. Patients who developed fellow-eye neovascularization and those exhibiting GA without neovascularization at the final follow-up were included in the neovascularization and GA groups, respectively. The patient demographics and baseline fellow-eye characteristics were compared between the two groups.

RESULTS

The mean follow-up period was 40.5 ± 11.5 months after diagnosis. Patients included in the GA group (n = 28) were significantly older (mean 77.4 ± 5.2 years vs. 74.2 ± 5.8 years, P = 0.016), had significantly thinner subfoveal choroidal thickness (mean 109.4 ± 36.8 µ m vs. 173.1 ± 77.6 µ m, P < 0.001), and had a significantly higher incidence of baseline GA (39.3% vs. 16.1%, P = 0.019) than those included in the neovascularization group (n = 56). In the multivariate analysis, subfoveal choroidal thickness showed a close negative association with the risk of GA rather than neovascularization ( P = 0.004, β = 0.982, 95% confidence interval = 0.970-0.994).

CONCLUSION

In patients with unilateral Type 3 macular neovascularization, older age, the presence of GA, and a thin choroid in the fellow eye were found to be indicative of a higher probability of progression toward fellow-eye GA instead of neovascularization may be potential candidates for future complement inhibitor treatments targeting fellow-eye GA.

Prevalence and Distribution of Macular Fluid with Central Retinal Artery Occlusion and Anterior Ischemic Optic Neuropathy

Purpose

To examine the prevalence and distribution of fluid within a cohort of eyes with acute central retinal artery occlusion (CRAO) and non-arteritic anterior ischemic optic neuropathy (AION) using optical coherence tomography (OCT).

Methods

A retrospective analysis of patient records and OCT imaging. Patients presenting with acute CRAO or AION who had available macular OCT imaging and no co-morbidities known to cause macular fluid were included in the analysis. Baseline characteristics, visual acuity (VA), and fluid presence and distribution among the retinal layers were recorded.

Results

In the 16 eyes with acute CRAO, fluid was noted in 5 eyes (31%), which was mainly subretinal (3 eyes) or intraretinal located within the outer retinal layers (3 eyes). Only one eye had inner retinal cysts. Of the 11 eyes with acute AION, fluid was present in 8 eyes (73%). Subretinal fluid was noted in 4 eyes and extended to the foveal area in 3 of them, and outer retinal versus inner retinal cysts were noted in 6 versus 3 eyes, respectively. None of the eyes showed hard exudate deposition. In the small subset of eyes with CRAO and macular fluid that were followed-up, VA improved, while in eyes with AION, VA remained stable.

Conclusion

Macular fluid on OCT is not an uncommon feature of acute CRAO and AION and is mainly distributed within the outer retinal layers or subretinal space. Fluid is an understudied feature of retinal and optic nerve head infarction and may have a role in predicting neuronal damage extent and visual outcome.

Fixed Quarterly Dosing of Aflibercept after Loading Doses in Neovascular Age-Related Macular Degeneration in Chinese Eyes

We aimed to investigate the success rate of planned fixed quarterly aflibercept injections after three loading doses (QDA3L) to achieve stability without recurrence in neovascular age-related macular degeneration (nAMD) at a tertiary eye centre. A retrospective study was conducted over five years (2017-2021) by including all consecutive cases of nAMD treated with three initial aflibercept injections four weeks apart, followed by planned injection appointments every 12 to 16 weeks starting from week 20. The primary endpoint was to determine the proportion of patients who maintained disease inactivity at week 52 and week 104. A total of 40 eyes of 40 patients were included. The overall mean age was 80.8, with a male preponderance. The overall success rate in our study population was 52.9% and 53.6% at week 52 and week 104, respectively. The fovea remained dry at 85.3% at week 52 and 82.1% at week 104, and 85.3% and 85.7% of subjects lost fewer than 15 ETDRS letters at week 52 and week 104, respectively. While this study does not suggest the superiority of this regimen, the success and failure rates obtained in our study can be used in the counselling process for this particular fixed treatment regimen for nAMD.

Recent Advances in Imaging Macular Atrophy for Late-Stage Age-Related Macular Degeneration

Age-related macular degeneration (AMD) is a leading cause of blindness worldwide. In late-stage AMD, geographic atrophy (GA) of dry AMD or choroidal neovascularization (CNV) of neovascular AMD eventually results in macular atrophy (MA), leading to significant visual loss. Despite the development of innovative therapies, there are currently no established effective treatments for MA. As a result, early detection of MA is critical in identifying later central macular involvement throughout time. Accurate and early diagnosis is achieved through a combination of clinical examination and imaging techniques. Our review of the literature depicts advances in retinal imaging to identify biomarkers of progression and risk factors for late AMD. Imaging methods like fundus photography; dye-based angiography; fundus autofluorescence (FAF); near-infrared reflectance (NIR); optical coherence tomography (OCT); and optical coherence tomography angiography (OCTA) can be used to detect and monitor the progression of retinal atrophy. These evolving diverse imaging modalities optimize detection of pathologic anatomy and measurement of visual function; they may also contribute to the understanding of underlying mechanistic pathways, particularly the underlying MA changes in late AMD.

Imaging Histology Correlations of Intraretinal Fluid in Neovascular Age-Related Macular Degeneration

Purpose

Fluid presence and dynamism is central to the diagnosis and management of neovascular age-related macular degeneration. On optical coherence tomography (OCT), some hyporeflective spaces arise through vascular permeability (exudation) and others arise through degeneration (transudation). Herein we determined whether the histological appearance of fluid manifested this heterogeneity.

Methods

Two eyes of a White woman in her 90s with anti-vascular endothelial growth factor treated bilateral type 3 neovascularization secondary to age-related macular degeneration were osmicated, prepared for submicrometer epoxy resin sections, and correlated to eye-tracked spectral domain OCT. Examples of intraretinal tissue fluid were sought among similarly prepared donor eyes with fibrovascular scars, in a web-based age-related macular degeneration histopathology resource. Fluid stain intensity was quantified in reference to Bruch's membrane and the empty glass slide.

Results

Exudative fluid by OCT was slightly reflective and dynamically responded to anti-vascular endothelial growth factor. On histology, this fluid stained moderately, possessed a smooth and homogenous texture, and contained blood cells and fibrin. Nonexudative fluid in degenerative cysts and in outer retinal tubulation was minimally reflective on OCT and did not respond to anti-vascular endothelial growth factor. By histology, this fluid stained lightly, possessed a finely granular texture, and contained mainly tissue debris. Quantification supported the qualitative impressions of fluid stain density. Cells containing retinal pigment epithelium organelles localized to both fluid types.

Conclusions

High-resolution histology of osmicated tissue can distinguish between exudative and nonexudative fluid, some of which is transudative.

Translational Relevance

OCT and histological features of different fluid types can inform clinical decision-making and assist in the interpretation of newly available automated fluid detection algorithms.

The complement system: a novel therapeutic target for age-related macular degeneration

INTRODUCTION

With the recent FDA approvals of pegcetacoplan (SYFOVRE, Apellis Pharmaceuticals) and avacincaptad pegol (IZERVAY, Astellas Pharmaceuticals), modulation of the complement system has emerged as a promising therapeutic approach for slowing progression of geographic atrophy (GA) in AMD.

AREAS COVERED

This article reviews the current understanding of the complement system, its role in AMD, and the various complement-targeting therapies in development for the treatment of GA, including monoclonal antibodies, aptamers, protein analogs, and gene therapies. Approved and investigational agents have largely focused on interfering with the activity of complement components 3 and 5, owing to their central roles in the classical, lectin, and alternative complement pathways. Other investigational therapies have targeted formation of membrane attack complex (a terminal step in the complement cascade which leads to cell lysis), complement factors H and I (which serve regulatory functions in the alternative pathway), complement factors B and D (within the alternative pathway), and complement component 1 (within the classical pathway). Clinical trials investigating these agents are summarized, and the potential benefits and limitations of these therapies are discussed.

EXPERT OPINION

Targeting the complement system is a promising therapeutic approach for slowing the progression of GA in AMD, potentially improving visual outcomes. However, increased risk of exudative conversion must be considered, and further research is required to identify clinical criteria and best practices for initiating complement inhibitor therapy for GA.

Prevalence of Geographic Atrophy in Advanced Age-Related Macular Degeneration (AMD) in Daily Practice

PURPOSE

To investigate the prevalence of geographic atrophy (GA) in advanced age-related macular degeneration (AMD) and the proportion of eyes that would meet the indication criteria for treatment with the first intravitreal anti-C3 agent (pegcetacoplan).

METHODS

This retrospective cross-sectional study included all AMD patients who visited the Macular-Retina-Centre Oberkassel in 2021. Eyes were classified according to AMD stages. Eyes with GA were divided into two groups regarding foveal involvement. Baseline factors were compared between eyes with foveal GA (FGA) and eyes with non-foveal GA (NFGA) to identify predictive factors for foveal involvement.

RESULTS

A total of 2033 eyes from 1027 patients were included. AMD stage was early in 296 (14.5%) cases, intermediate in 368 (18.1%) cases, and advanced in 1249 (61.4%) cases. A total of 1204 (60%) eyes had GA [932 (77%) FGA and 272 (23%) NFGA], while 125 eyes (27.4% from eyes with advanced dry AMD) met the indication criteria for treatment with intravitreal pegcetacoplan. The proportion of eyes with neovascular AMD was significantly higher in the FGA group compared to the NFGA group [598 (64.2%) vs. 152 (55.8%), p = 0.01].

CONCLUSIONS

At least a quarter of eyes with advanced AMD would be suitable for the upcoming intravitreal pegcetacoplan therapy. Foveal involvement of GA in advanced AMD seems to be more likely in neovascular AMD than in dry AMD.